The Amazing Adventures of Captain Redeye
Doug Franzen, MD, M.Ed, FACEP
University of Washington
Red Eye Gravy
DDX of “Red Eye”
Conjunctivitis
Trauma / Abrasion
Something in the eye Glaucoma
Subconj. Hemorrhage
…
Other Stuff
DDX of “Red Eye”
Blepharitis, Adult Burns, Chemical Canaliculitis
Cellulitis, Orbital Cellulitis, Preseptal Chalazion Cicatriacal Pemphigoid
Cluster Headache
Conjunctival Neoplasia
Conjunctivitis, Acute Hemorrhagic Conjunctivitis, Allergic/Atopic/vernal Conjunctivitis, Bacterial Conjunctivitis, Giant Papillary Conjunctivitis, Neonatal Conjunctivitis, Viral Contact Lens Complications Corneal Abrasion Corneal Erosion, Recurrent Corneal Foreign Body Corneal Graft Rejection Dacryocystitis Distichiasis Dry Eye Syndrome Ectropion Endophthalmitis, Bacterial Endophthalmitis, Fungal Endophthalmitis, Postoperative Entropion Glaucoma, Angle Closure, Acute Herpes Simplex Herpes Zoster Hordeolum Iritis/Anterior Uveitis/Iridiocyclitis
Keratoconjunctivitis Sicca
Lagoophthalmos
Meibomianitis
Pterygium/Pingueculae
Scleritis/Episcleritis
Subconjunctival Hemorrhage
Stevens Johnson Syndrome
Superficial Punctate Keratitis
Trauma
Trichiasis
Case 1
52 year old male c/o right eye redness, discomfort
and FB sensation for three days.
ROS: Pain, blurred vision, photophobia. No
Fevers/Sore throat/Cough. No N/V/D.
PMhx: DM, HTN, gout, A-fib
Medications: Coumadin, Insulin, Norvasc,
Indomethacin
Allergies: Sulfa
VS: 140/95, 94, 18, 97.6, 100%RA
Case 1
Eye Exam:
•  VA 20/40
•  EOMI
•  Pupils ERL; photophobia
Case 1
•  “A little fluorescein
uptake. I think it’s
an abrasion.”
The Slit Lamp is So Far Away!
x
Wood’s Lamp –
3x magnifying glass
x
Slit Lamp –
40x microscope
Case 1
My Eye Exam:
•  VA 20/30(os) Counts fingers at ~5 feet(od)
•  Upper lid swollen, mildly erythematous
•  EOMI
•  Pupils ERL; pain in R eye when light shined in either eye
Ciliary Flush
Case 1
My Eye Exam:
•  VA 20/30(os) Counts fingers at ~5 feet(od)
•  EOMI
•  Pupils ERL; pain in R eye when light shined in either eye
•  Slit Lamp
– 
– 
– 
– 
– 
– 
R eyelid is erythematous
Lashes/Lacrimal ducts appear normal
Conjunctival hyperemia, tearing
Ciliary flush
Cornea with poor light reflex, appears dull
Anterior Chamber:
Case 1
Case 1: Herpes Keratitis
Punctate Epithelial Keratitis
Case 1
Nummular Keratitis
Case 1: Herpes Keratitis
Workup/Treatment/Dispo
1) Ophtho Consult
2) Oral Antivirals
3) Topical Antibiotics
4) Artificial Tears
5) Topical Steroids?
6) Ensure Ophtho F/U
Evaluating the Eye
•  Chemical?
–  Decontaminate, check pH
•  Sudden loss of vision?
–  Visual fields, fundoscopy, ultrasound
•  All others:
–  Visual acuity (vital signs of the eye)
–  Complete Eye Exam
–  Focused H&P
Evaluating Eye Complaints
•  Painful: FB sensation? Itching? Achy?
–  Photophobia?
•  Red: Injected? Trauma?
•  Discharge: Watery? Mucoid? Purulent?
•  Change in vision
–  “Blurry” or blurry? Loss of vision? Diplopia?
•  Other Pertinent History:
–  Contacts? Glaucoma? Systemic problems?
The Eye Exam in 10 Parts 1) 
2) 
3) 
4) 
5) 
Visual Acuity – check each eye individually
Gross: EOM, proptosis, swelling, etc
Pupil exam
Adnexa: Lacrimal, Lids, Lashes
Conjunctiva:
-  pattern of redness (superficial vs. deep vessels; bulbar vs. palpebral)
-  Hyperemia? Chemosis?
-  Discharge: Scant, profuse, watery, thick, purulent
6)  Cornea: edema, lesions, precipitates, reflection
7)  Fluoroscein stain!
8)  Anterior Chamber: estimate depth, blood or pus, cell/flare
9)  IOP
10)  Fundoscopic +/- Ultrasound
Note: order may vary, depending on your ddx & availability of
equipment
Visual Acuity
Can’t see the wall chart?
Record vision as:
• count fingers
–  (e.g., CF at 5ft),
• hand motion
–  (HM at 2 ft),
• light perception (LP), or
• no light perception (NLP).
• Pinhole if they forgot
glasses
The Eye Exam in 10 Parts 1) 
2) 
3) 
4) 
5) 
Visual Acuity – check each eye individually
Gross: EOM, proptosis, swelling, etc
Pupil exam
Adnexa: Lacrimal, Lids, Lashes
Conjunctiva:
-  pattern of redness (superficial vs. deep vessels; bulbar vs. palpebral)
-  Hyperemia? Chemosis?
-  Discharge: Scant, profuse, watery, thick, purulent
6)  Cornea: edema, lesions, precipitates, reflection
7)  Fluoroscein stain!
8)  Anterior Chamber: estimate depth, blood or pus, cell/flare
9)  IOP
10)  Fundoscopic +/- Ultrasound
Note: order may vary, depending on your ddx & availability of
equipment
“All that is red is not conjunctivitis” -J.R.R. Tolkein (maybe)
Conjunctivitis
Iritis
Acute Glaucoma
MARKED
None
None
Slight or none
None
MARKED
Slight
Slight to marked
None / itchy
Slight to
marked
MARKED
MARKED
Visual Acuity
Normal
Reduced
Reduced
Varies with site of
the lesion
Pupil
Normal
SMALLER or
same
LARGE and
FIXED
Same or
SMALLER
Discharge
Photophobia
Pain
Keratitis
(foreign body abrasion)
Distributed in the public interest by the Section on Ophthalmology of the Ontario Medical Association
Eye Exam: Red Flags
Symptoms:
-Blurred Vision
-Severe Pain
-Photophobia
-Colored Halos
Signs:
-  Reduced VA
-  Esp. in affected eye
- Ciliary Flush
- Corneal Opacification
- Corneal Epithelial damage
- Pupillary Abnormalities
- Pain with consensual
reaction
- Abnml Ant. Chamber
- Elevated IOP
- Proptosis
Case 2
35 y/o male, right eye redness, pain: foreign
body sensation, photophobia. Watery
since yesterday.
Yesterday was trimming tree branches.
PMHx: none
Allergies: none
VS: 120/80 12 98.6 70 100%RA
Case 2
Case 2
Case 2
Case 2
Case 2
Case 2 - Corneal FB/Abrasion
1) F/U with Ophtho
Immediate:
-  cannot remove FB
-  large area or central
visual axis
-  Deep ulcer / risk of
perforation
-  concern for intraocular FB
-  “missle”
-  Irregular pupil
-  Corneal perforation
-  Corneal Ulcer*
Urgent / Next Day:
-  Able to remove
-  Does not involve axis
-  Simple abrasion
Case 2 - Corneal FB/Abrasion
1) Arrange appropriate followup
2) Cycloplegics
3) Consider topical NSAIDS(ketorolac/diclofenac/
indomethacin) - $$$
4) Topical Antibiotics (antipseudomonal if contact wearer)
5) Artificial tears
6) Oral analgesics
7) Tetanus
Corneal Ulcer
Corneal Ulcer
Case 2
Case 3
24 y/o male presents with left eye redness,
dull, aching pain & photophobia for 1 day.
ROS: No eye discharge/tearing. Mild blurred
vision. Fatigue, achy. No N/V/D.
PMhx: Neg (several ED visits for low back
pain noted on chart review)
VS: 120/85, 20, 99.0, 65, 100%RA
Case 3
• 
• 
• 
• 
VA – 20/40 OD, 20/20 OS
EOMI
PERRL; pain with consensual reaction
Lids/lashes/lacrimal normal
Case 3
Case 3
Case 3
Case 3
Keratic Precipitates
Case 3 – Uveitis / Iritis
Symptoms: Pain, red eye, photophobia (consensual
photophobia), Decreased vision(chronic)
Exam: Ciliary Flush, Cells and Flare in Anterior Chamber,
Keratic Precipitates
W/U: Complete ocular exam, including IOP and dilated
funduscopic
Lab workup
Ophthalmology referral
Consider rheumatology referral
Case 3 – Uveitis / Iritis
Acute Causes:
- HLA-B27
- idiopathic - postoperative iritis
- lens induced
- Behcet
- Kawasaki
- Infectious: Lyme, mumps, influenzae, adenovirus,
measles, Leptospirosis, rickettsia
Chronic: Sarcoidosis, Herpes Simplex, Syphilis, TB
Case 3 - Iritis
Workup / Treatment / Dispo
1) (+/-)Ophtho Consult
2) Topical Steroids
3) Long Acting Cycloplegics
4) Lab workup (for outpatient f/u)
5) Chest X-ray
6) Ensure Ophtho Follow up
Case 4
55 y/o Hispanic male complains of left eye
redness, itching, intermittent, FB? for several
months. Slight blurred vision in same eye for
couple weeks.
ROS: (-)Photophobia, (-)Pain
PMhx: none known
All: none
Social: Field worker for most of life
VS: 175/100, 16, 97.5, 85, 100%RA
Case 4
Case 4
Case 4
•  Pterygium: wing shaped fold of fibrovascular
tissue arising from interpalpebral conjunctiva and
extending onto the cornea. Usual nasal in
location.
•  Pinguecula: Yellow-white, flat or slightly raised
conjunctival lesion, usually in the interpalpebral
fissure, adjacent to the limbus, but not involving
the cornea.
Case 4: Pterygium Workup:
Eye Exam(Document VA!)
Rule out FB/Abrasion
(Fluorescein and anesthetic)
Treatment/Dispo:
1) Nonurgent ophtho referral
2) Artificial Tears
3) Consider Topical Steroids(for
inflamed pinguecula) – discuss
with ophtho
4) Protect eyes from sun, dust,
and wind
5) Surgical Excision-cosmetic,
when pterygium broaches the
visual axis, recurrent
symptoms
Case 5
48 year female complains of right eye redness and
mild pain for 3 days. Similar symptoms several
months ago.
ROS: No discharge, photophobia, trauma/FB. No
hx of allergic symptoms. No N/V or headache.
PMhx: SLE
All: none
Meds: None (prev. prednisone for SLE flares)
VS: 120/80 80 20 97.8 100%RA
Case 5
Case 5:Episcleritis
• 
• 
• 
• 
Inflammatory condition of episcleral tissue
Poorly understood
Lasts 7-10 days; often returns every few months
Most cases idiopathic; also associated with autoimmune
diseases and some infections (including syphilis &
tuberculosis).
Treatment – (usually self limited)
Artificial Tears, Oral NSAIDS, follow up (may prescribe mild
topical steroid)
***Need to distinguish from Scleritis!!
Scleritis
•  Extremely painful – deep, aching
–  May also complain of pain with EOM
•  Engorgement of deep scleral vessels
–  May be diffuse or localized
–  Phenylephrine will constrict superficial vessels but
not deep vessels
•  Sclera may have a blue/purple color due to
thinning
•  About ½ have associated anterior chamber
involvement
Scleritis
Subconjunctival Hemorrhage
Case 6
25 year female presents with “pink eye” for 2 days.
ROS: Redness, FB sensation, purulent discharge.
No Photophobia. Mild blurred vision. No recent
URI symptoms. Eyelids sticking (worse in
mornings).
PMhx: None.
Meds: None
Social: Not sexually active
VS: 120/80 80 20 97.8 100%RA
Nurse documents 20/20(os) 20/200(od) on chart
Case 6
Viral vs. Bacterial Conjunctivitis
Viral
•  Known contact
•  URI symptoms
• 
•  Watery Discharge
•  Preauricular node
•  Follicular bumps on
eyelids
• 
• 
• 
Bacterial
Purulent / creamy
discharge
No preauricular node
Papillary bumps on
eyelids
Prefers fornix
Viral vs. Bacterial
Bacterial Conjunctivitis
Common Organisms:
S. Aureus, S. Epidermidis, Strep Pneumoniae, and
H. Influenzae
1) Topical antibiotic drops v. ointment
–  trimethoprim/polymyxin or fluoroquinolone drops or bacitracin
5-7 days.
–  Eye drops do not interfere with vision, ointment soothing
2) Follow up if not improving or getting worse
Summary/Pearls
1)  CC: “pink eye” is
often not
2)  Focused History
3)  Do a consistently
thorough eye exam –
watch for red flags
4)  Use the slit lamp –
the more you do, the
better you’ll get
Case 10
8 year old male with 3 days of right eyelid pain and
swelling.
ROS: Eye “discomfort” with burning sensation in
right eye. No photophobia. No previous trauma.
No previous eyelid lesions. No discharge.
PMhx: none
All: none
Meds: none
VS: 120/80 80 20 98.6 100%RA
Case 10
Case 10:Hordeolum and Chalazion
Hordeolum vs. Chalazion
Hordeolum
•  Acute
•  Painful
•  Infection of the
sebacious (Zeis or
Moll) or meibomian
glands, or sometimes
lid margin
•  90% Staph
Chalazion
•  Chronic
•  Often painless –
–  but may become
inflammed
•  Granuloma of
meibomian glands
•  May result from
chronic hordeolum
Hordeolum Pathophysiology
Case 10: Hordeolum(Stye)
Treatment:
1) Warm compresses
2) Topical antibiotic (bacitracin optho ointment)
- usually self-limited
3) If fails to resolve in 3-4 weeksà optho
4) Multiple lesions/preseptal cellulitis treat with oral
antibiotics.
5) Consider teaching lid hygiene to patients who
get this frequently
What’s this?
Blepharitis
Blepharitis refers to a consistent inflammatory process
around the eyelid/lashes that comprise bacterial
colonization and a seborrheic-type dermatitis.
Treated with topical antibiotics and special hygiene
of lids.
Vocabulary Quiz
Chemosis
•  Conjunctival Edema
Vocabulary Quiz
Hyphema
•  Blood in anterior
chamber
Vocabulary Quiz